The study explores the effects of discontinuing P2Y12 receptor inhibitors before undergoing isolated on-pump coronary artery bypass grafting (CABG). Dual antiplatelet therapy (DAPT) is commonly used to prevent thrombotic events in patients with acute coronary syndrome (ACS) but raises the risk of perioperative bleeding. Current guidelines recommend stopping P2Y12 inhibitors at least three, five, or seven days before surgery for ticagrelor, clopidogrel, and prasugrel, respectively. However, in clinical practice, adherence to these guidelines varies, leading to uncertainty about optimal management strategies.
Using an individual patient data meta-analysis (IPD-MA), researchers aggregated data from seven observational studies involving 4,837 patients. The primary outcome of interest was severe bleeding (BARC-4), defined as intracranial bleeding, reoperation for bleeding, transfusion of ≥5 red blood cell units, or chest tube output of ≥2 liters. Secondary outcomes included 30-day mortality and postoperative ischemic events.
The study found that BARC-4 bleeding occurred in 20% of patients, while 30-day mortality and postoperative ischemic events were observed in 2.6% and 5.2% of patients, respectively. After adjusting for risk factors like EuroSCORE II and cardiopulmonary bypass time, patients who adhered to guideline-recommended withdrawal times had a significantly lower risk of severe bleeding—by 50% for clopidogrel users and a similar trend for ticagrelor. Importantly, longer withdrawal times did not lead to an increased risk of ischemic events or mortality.
A key finding was that patients undergoing surgery within 24 hours of stopping ticagrelor or clopidogrel had significantly higher BARC-4 bleeding rates (39.7% and 27.9%, respectively). Prasugrel users had the highest bleeding rates, with 57% experiencing BARC-4 bleeding within a day of drug cessation. The study also explored patient subgroups, finding that guideline-conforming withdrawal benefited both anemic and non-anemic patients, reinforcing its importance across different risk profiles.
This analysis supports the continued adherence to standardized withdrawal guidelines, demonstrating that a delay in surgery to allow for proper platelet function recovery can significantly reduce severe bleeding without worsening ischemic outcomes. The findings suggest that clinical decisions should prioritize guideline-based withdrawal periods, and further research should focus on optimizing perioperative antiplatelet management strategies.
